Relative value to surgical patients and anesthesia providers of selected anesthesia related outcomes

BACKGROUND: Anesthesia side effects are almost inevitable in most situations. In order to optimize the anesthetic experience from the patient's viewpoint, it makes intuitive sense to attempt to avoid the side effects that the patient fears the most. METHODS: We obtained rankings and quantitative estimates of the relative importance of nine experiences that commonly occur after anesthesia and surgery from 109 patients prior to their surgery and from 30 anesthesiologists. RESULTS: Pain was the most important thing to avoid, and subjects allocated a median of $25 of an imaginary$100 to avoiding it. Next came vomiting ($20), nausea ($10), urinary retention ($5), myalgia ($2) and pruritus ($2). Avoiding blood transfusion, an awake anesthetic technique or postoperative somnolence was not given value by the group as a whole. Anesthesiologists valued perioperative experiences in the same way as patients. CONCLUSIONS: Our results are comparable with those of previous studies in the area, and suggest that patients can prioritize the perioperative experiences they wish to avoid during their perioperative care. Such data, if obtained in the appropriate fashion, would enable anesthetic techniques to be compared using decision analysis

Total Intravenous Anesthesia to Reduce Metastasis and Recurrence Rates in Patients Presenting for Breast Cancer Surgery: An Educational Intervention

Background: Surgical intervention for breast malignancy is the treatment of choice for the breast cancer patient population. Extensive research has established the correlation between the mode of anesthetic delivery and breast cancer recurrence and metastasis in patients undergoing surgical intervention for breast cancer. Researchers have identified the implications of volatile anesthetic agents (VAA), or inhalational agents, on the suppression of the immune response throughout the perioperative period; thus, cultivating an environment that is ideal for cancer cell proliferation, migration, and eventual metastasis via systemic circulation. Although the standardization of the anesthetic management for this patient population has not been declared, total intravenous anesthesia (TIVA) has been identified as the optimal anesthetic method to reduce the risk of breast cancer recurrence and metastasis in patients undergoing breast surgery, due to the immunologic protectant effects proffered by the drugs utilized in TIVA anesthetic administration. Methods: PubMed, Google Scholar, and the Cumulative Index of Nursing and Allied Health Literature (CINAHL) search engines were accessed via the Florida International University (FIU) library database to compose a comprehensive search for peer-reviewed research studies within the last 10 years that examined the effects of VAA or TIVA anesthetic on breast cancer recurrence and metastasis in patients undergoing surgical intervention for breast cancer. Results: Eight high-level research articles were selected for appraisal and inclusion of this review due to novelty and relevance. The articles included in this review evaluate the long-term effects of VAA or TIVA anesthetic delivery on breast cancer recurrence and metastasis in the breast cancer patient surgical population and identify the existing research-to-practice gap that must be addressed in the anesthesia community to yield the best possible outcomes for the aforementioned target population. Conclusion: Current evidence-based research has illuminated the impactful role that anesthesia providers may have on the long-term outcomes of patients with breast malignancy presenting for surgical intervention via the selection of a TIVA-based anesthetic approach. It is anticipated that the implementation of a QI project will enhance the anesthesia providers’ capacity to improve the quality of life and reduce the risk of life-altering implications with the selection of their anesthetic approach in breast cancer patients

Improving Anesthesia Provider Knowledge and Competence in Patient Blood Management

Background: In the United States, blood transfusions are the most common medical procedure performed in hospitals. When used appropriately, allogeneic blood transfusions are crucial life-saving interventions essential in perioperative management. The use of blood transfusions should be based on safety, efficacy, and quality of treatment. However, a significant volume of evidence has emerged correlating blood transfusions to adverse patient outcomes, increases in cost, increases in morbidity, and mortality in surgical patients. Noting this, current transfusion practices require further evaluation. Patient Blood Management is a novel multidisciplinary approach that mitigate these negative outcomes. Methods: A comprehensive literature search was conducted using CINAHL and MEDLINE databases to identify research studies from 2015 and forward that have evaluated the effectiveness of Patient Blood Management in reducing morbidity, mortality, and excess costs associated with inappropriate allogeneic blood transfusion administration. Results: A total of 8 research studies were identified for review. These studies analyzed various treatment modalities within Patient Blood Management. The articles affirm the reliability and validity of the initiative in reducing the overutilization allogeneic blood transfusions in the perioperative period and thus reducing the associated adverse outcomes and cost

Norepinephrine Use In Septic Patients Undergoing General Anesthesia

Anesthesia providers are frequently confronted by the problem of caring for patients presenting with sepsis in the operating room. Sepsis is associated with high healthcare costs and a significant mortality rate despite advancements in the understanding of its complicated pathophysiology. The 2016 Surviving Sepsis Campaign recommends norepinephrine as the first-choice vasopressor in septic patients. Its mild beta-adrenergic effects, in addition to its alpha-adrenergic effects, make it an attractive agent for the vasoplegia and myocardial dysfunction associated with sepsis. Earlier achievement of adequate perfusion pressures, earlier lactate clearance, and higher in-hospital survival have all been associated with norepinephrine use in the septic patient. However, it remains underutilized in the perioperative setting. Peripheral intravenous administration of norepinephrine has been associated with very low complication rates and norepinephrine, as an alternative to other vasopressors in patients undergoing general anesthesia, is showing promising results. In patients with sepsis requiring surgical source control, anesthesia providers should see themselves as key players in the critical care continuum and should be encouraged to consider the use of norepinephrine

Improving Anesthesia Provider Knowledge and Competence in Patient Blood Management

Background: In the United States, blood transfusions are the most common medical procedure performed in hospitals. When used appropriately, allogeneic blood transfusions are crucial life-saving interventions essential in perioperative management. The use of blood transfusions should be based on safety, efficacy, and quality of treatment. However, a significant volume of evidence has emerged correlating blood transfusions to adverse patient outcomes, increases in cost, increases in morbidity, and mortality in surgical patients. Noting this, current transfusion practices require further evaluation. Patient Blood Management is a novel multidisciplinary approach that mitigate these negative outcomes. Methods: A comprehensive literature search was conducted using CINAHL and MEDLINE databases to identify research studies from 2015 and forward that have evaluated the effectiveness of Patient Blood Management in reducing morbidity, mortality, and excess costs associated with inappropriate allogeneic blood transfusion administration. Results: A total of 8 research studies were identified for review. These studies analyzed various treatment modalities within Patient Blood Management. The articles affirm the reliability and validity of the initiative in reducing the overutilization allogeneic blood transfusions in the perioperative period and thus reducing the associated adverse outcomes and cost

A Pain Control Optimization Pathway to Reduce Acute Postoperative Pain and Opioid Consumption Postoperatively: An Approach to Battling the Opioid Epidemic

Practice Problem: Healthcare providers worldwide are working to battle the opioid epidemic and reduce opioid-related harm to patients. Utilizing evidence-based acute pain management methods to reduce opioid consumption is critical to combat the problem. PICOT: The PICOT question that guided this project was: In opioid-naïve adult patients undergoing general anesthesia for out-patient, minimally invasive abdominal wall hernia surgery, how does the implementation of an evidence-based, preventative Pain Control Optimization Pathway (POP) using a multimodal, opioid-sparing acute pain management technique and standardized procedure-specific opioid prescribing, compared to standard treatment, affect postoperative pain scores and opioid consumption, upon discharge from the recovery room and 72 hours postoperative? Evidence: Evidence supported utilizing a multimodal, opioid-sparing acute pain management technique, patient counseling, and opioid prescribing guidelines to improve outcomes among opioid-naïve patients undergoing abdominal surgeries. Intervention: In this pre- and post-intervention evaluation, N = 28 patients received the POP care process during the perioperative period. Outcome: Results showed the mean pain score at discharge from the recovery room decreased from 4.8 to 2.82 on the 10-point Numeric Rating Scale post-intervention (p\u3c 0.001). Also, provider compliance with prescribing a procedure-specific opioid prescription increased from 73% to 100%, thus reducing opioid exposure and access. Conclusion: This project provided evidence that utilization of the innovative POP care process provided optimal pain control and decreased opioid consumption, consequently reducing the risk of new persistent opioid use

Evaluating the Likelihood of Use of Bispectral Index Guided Anesthesia as a Strategy to Reduce Postoperative Delirium in Surgical Patients 65 Years of Age or Older

Postoperative delirium (POD) is the most common postoperative complication in the elderly, accounting for approximately $164 billion in costs per year in the United States (Inouye, Westendorp, & Saczynski, 2014, p. 911). This complication occurs in as many as 50% of elderly patients, but can be prevented as much as 40% of the time (Inouye et al., 2014). The use of processed encephalographic monitoring, such as Bispectral Index (BIS) monitoring, to guide anesthetic dosage is the single intraoperative intervention with enough evidence to support it as a recommendation for use to reduce POD (American Geriatrics Society, 2015). There were two parts to this project. The goal of part 1 was to evaluate recent trends in BIS monitor use for patients 65 years of age or older through retrospective chart review. The goal of part 2 was to conduct a voluntary survey to assess anesthesia provider’s knowledge of current recommendations, opinions, barriers to use, and if there are plans for practice change related to BIS monitor use. Data collected during part 1 demonstrated the odds ratio of BIS use in this sample overall 0.078, indicating that the likelihood of BIS being used in this sample was 12.8 times lower than BIS not being used (n=281, p

Assessing Post Operative Information Transfers: Evaluation of Patient Outcomes

Purpose: The purpose of this dissertation research was to study postoperative handover information transfers (PITS) and to ultimately improve patient safety and patient outcomes. One of the goals was to identify deficits in PITS by exploring information needs and processes related to PITS. Grounded by the social ecological model (SEM), a scoping review of extant literature was conducted to identify individual, interpersonal, organizational environmental and organizational policy level factors that influence the quality and processes of post-operative information transfers (PITS). An integrative review of extant literature was conducted to describe how PITS have been studied and to describe instruments that have been developed to improve PITS. Using participatory action research, a sequential mixed-methods study was undertaken to assess the feasibility of and pilot test the electronic post-operative information transfer instrument (EPITI). Problem: PITS have been described as fraught with errors and prone to information omissions (Catchpole, Sellers, Goldman, McCulloch, & Hignett, 2010; Segall et al., 2012, 2012). Information transfers between anesthesia providers and post anesthesia care unit nurses take place among a myriad of other patient care activities including re-establishing monitoring technology while communicating the verbal report (Smith, Pope, Goodwin, & Mort, 2008). Deficits in PITS have been associated with delays in medical treatment, and increased morbidity and mortality (Nagpal et al., 2013; Rose & Newman, 2016; van der Walt & Joubern, 2014). Previous research has shown that standardization of PITS increases the amount of information transferred (Potestio, Mottla, Kelley, & DeGroot, 2015; Salzwedel et al., 2013; Siddiqui et al., 2012) One way PITS have been standardized is by including post-operative information transfer forms within anesthesia information management systems (AIMS). Research is needed to assess the feasibility of implementing AIMS, including the EPITI by gaining insight from key stakeholders, defined as anesthesia providers (AP) and PACU nurses. Additional research is needed that describes the development, implementation and evaluation of electronic PIT instruments. The purposes of the manuscripts included in this dissertation were: Manuscript I Scoping Review: To identify factors at each level of the Social Ecological Model that influence PITS Manuscript II Integrative Review: To describe and synthesize instruments developed to improve PITS and to describe how PITS have been studied Manuscript III Pilot and Feasibility Study: To report on pilot testing and evaluation of the feasibility of the electronic post-operative information transfer instrument (EPITI) Design: Sequential mixed methods using a participatory action approach Findings: Individual, interpersonal, organizational and environmental factors influence PITS. Efforts including standardization of PITS have been undertaken to decrease information omissions and to improve interpersonal communication. After pilot testing the EPITI, results of qualitative and quantitative data analysis showed the EPITI was feasible, acceptable and integrated well into clinical practice when pilot tested by AP and PACU nurses. Conclusion: Additional research is needed to implement and assess the effect of electronic postoperative handover instruments on patient specific outcomes

Evaluating Pre-Anesthesia Telehealth Visit Outcomes in Cardiac Surgery Patients at a Tertiary-level, Private, Academic Hospital

Telehealth is a dynamic, growing field in healthcare. Research has alluded to the potential of telemedicine in the pre-anesthesia area. With infection risk concerns brought to the forefront of healthcare due to the COVID pandemic, telemedicine offers an alternative evaluation method. Telehealth extends care to patients who otherwise would not have access to more comprehensive pre-anesthetic care and surveillance. Although studies show telemedicine\u27s potential and positive effects, institutions have not extended virtual visits for all cardiac surgery pre-anesthesia patients. This retrospective evaluation study aimed to assess the impacts of telehealth on cardiac surgery pre-anesthesia assessments in a tertiary-level, private, academic hospital. The study evaluated the intervention effects of 160 cases over 90 days, using Chi-square tests of independence to compare the traditional vs. telehealth means after the intervention to compare the impact that telehealth pre-anesthesia visits have on cardiac surgery cancellations and delays on the day of surgery. There were no significant differences between telehealth and face-to-face pre-anesthesia visits, indicating that this intervention can replace face-to-face where there is an option to do so with no increase in day-of-surgery cancellations that are costly and can result in inefficiencies. The results indicate the same conclusion for day-of-surgery cancellation impacts: the visit type was independent of the cancellation rates. Future exploration of telehealth evaluations can expand to other presurgical patients and specialty areas